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How Serious Games Will Improve Healthcare


Abstract and Figures

Games have the potential to attract large numbers of players and bring to them a specific understanding, skill, or attitude. The classic image of videogaming—socially deprived youngsters killing mystical monsters in their parents’ basement—has evolved into a highly social, everyday activity that attracts all age groups to play games in the family living room. Serious games, therefore, are increasingly recognized as methods to promote health, treat patients, and train healthcare professionals. Whereas the technological developments in software, platforms, and wearable sensors are moving at high speed, the number of potential applications is rising and so is their use. This chapter aims to give an overview of underlying game mechanisms, main healthcare-related purposes, and the evidence supporting their effectiveness. We conclude that although the field is maturing in terms of diversification and evidence, more high-quality trials are needed to gain insight into the effectiveness of individual games as well as methods to improve transparency for individual users and clinicians.
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H. Rivas, K. Wac (eds.), Digital Health, Health Informatics,
Chapter 10
How Serious Games Will Improve Healthcare
MauritsGraaand andMarliesSchijven
Abstract Games have the potential to attract large numbers of players and bring to
them a specic understanding, skill, or attitude. The classic image of videogam-
ing—socially deprived youngsters killing mystical monsters in their parents’ base-
ment—has evolved into a highly social, everyday activity that attracts all age groups
to play games in the family living room. Serious games, therefore, are increasingly
recognized as methods to promote health, treat patients, and train healthcare profes-
sionals. Whereas the technological developments in software, platforms, and wear-
able sensors are moving at high speed, the number of potential applications is rising
and so is their use. This chapter aims to give an overview of underlying game mech-
anisms, main healthcare-related purposes, and the evidence supporting their effec-
tiveness. We conclude that although the eld is maturing in terms of diversication
and evidence, more high-quality trials are needed to gain insight into the effective-
ness of individual games as well as methods to improve transparency for individual
users and clinicians.
Keywords Videogame • Education • Medical • Smartphone • Telemedicine •
Mobile health • Rehabilitation • Wearable technology
10.1 Introduction
In 2002, the United States Army launched America’s Army, a massive multiplayer
online videogame simulating combat situations. The army originally designed it to
be a “strategic communication platform” that would reach out to American
M. Graaand, M.D.Ph.D. (*) • M. Schijven, M.D., Ph.D., M.H.Sc.
Department of Surgery, Academic Medical Centre,
PO Box 22660, Amsterdam 1100, The Netherlands
e-mail: maurits.graa
youngsters. The game was played for over 40 million hours by 2.4 million regis-
tered users between July 2002 and November 2003 (Davis 2004). Because it encom-
passed highly realistic combat simulations, eld commanders soon started to use it
as a training and selection tool for new recruits (Zyda 2005).
This example perfectly illustrates the impact that well-designed serious games
may have. Serious games can be dened as the application of (digital) games to
improve users’ skills, knowledge, or attitudes in real life (Michael and Chen 2006).
In games, players are motivated by challenges, narrative, rules, and competitions to
actively display a particular behavior or solve a problem. That games are able to
trigger a player’s intrinsic motivation can be of particular use and signicance in the
eld of healthcare. This has been proven by the serious game Re-mission (HopeLab,
Palo Alto, CA, 2006), a freely available online videogame designed to help teenage
leukemia patients ght their disease. In this game, players virtually travel the blood
vessels and combat malignant cells. A randomized controlled trial shows an increase
in self-determination and drug adherence in patients playing the videogame,
whereas these individuals are typically exceptionally difcult to motivate to adhere
to medical treatment regimens (Kato etal. 2008).
Developments in the serious game industry have progressed rapidly in the past
decade. Adaptation in healthcare, however, has proved to be slow. As with any
healthcare innovation, the major concerns are safety and efcacy against costs for
development and maintenance. However, the eld may well have bypassed the ini-
tial peaks and disillusionments that many tech hypes experience. This chapter aims
to give an overview of serious games applied to the eld of medicine, evidence, and
future issues to be resolved.
10.1.1 Homo Ludens
Using games to enhance skills acquisition is not a new phenomenon. The
Russian Czar Peter the Great was known to build simulation armies to try out
different military scenarios and strategies (Konstam 1993). In the 1990s, the
rst educational videogames were introduced in high schools, sometimes
referred to as “edutainment” programs—mostly with little success (Susi etal.
2007). As the videogame industry developed into a multibillion-dollar industry
and computers became powerful enough to create complex simulations, the pos-
sibilities for creating more immersive and purposeful serious games have
increased greatly. New generations of serious games differ from edutainment in
that they rst and foremost attempt to attract and immerse the player into the
gameplay while simultaneously incorporating purposeful content in a subtle,
stealthy way (Susi etal. 2007; Sharp 2012).
User groups and their behavior have changed dramatically too. The common per-
ception of average gamers being overweight anti-social teenage boys spending their
days in their parents’ basement killing off monsters is long gone. The average gamer to
M. Graaand and M. Schijven
date is 35-years-old: 73% of all gamers are over 18-years-old and about 41% of them
are female. About 77% of gamers play at least 1h per week, 48% play games socially,
and 36% play games on their smartphones (Entertainment Software Association 2016).
10.2 Learning Through Challenge andFun
10.2.1 Flow Experiences
In well-designed games, interaction with the gameplay captivates the player. Series
of causally linked challenges keep a player motivated and engaged throughout the
game and, ideally, longing for more after he or she has quit playing. Gameplay
depends on the interaction between the player and a series of challenges presented
by the game, following specic (predictable or sometimes unpredictable) rules.
Good games evoke emotions and surprise, creating a positive experience in players.
Games are most effective when the player enters a state of ow (Kiili 2005). In this
state of mind, players become completely absorbed in the challenges presented to
them, ignoring all surroundings and focusing solely on playing. Flow experience
(Fig.10.1) results from an optimal balance between the game’s challenges and the
player’s abilities as illustrated by Csiksentmihalyi’s ow channel (Csikszentmihalyi
1975). Various factors are recognized to generate ow experience, such as clearly
dened goals, immediate and appropriate feedback, playfulness, surprise, usability,
and speed. Above all, players must sense that the challenges in the game match their
abilities as well as a level of control to avoid them from opting-out (Kiili 2005). A
player absorbed in a state of ow will learn more from the game, explore further,
display a more positive attitude toward the subject and feel more in control (Kiili
2005; Schüler 2007; Skadberg and Kimmel 2004).
Flow Channel
Level of Challenge
Level of skills
Fig. 10.1 Csikszentmihalyi’s ow channel shows the relation between challenges and player skills
in order to create an optimum experience in goal-driven activities (Schüler 2007)
10 How Serious Games Wi ll I mprove Healthcare
10.3 Physical andFunctional Fidelity
Games are ideal for problem-based learning as long as gameplay and educational
goals are sufciently balanced (Kiili 2005; Rollings and Adams 2003). Individuals
learn from gaming experiences through abstract conceptualization and forming
hypotheses, subsequently rening them in later experiences (Kolb 1984). If chal-
lenges, rules, and actions in the gameplay sufciently cohere with real-life situa-
tions, the transfer of knowledge and skills to reality will occur (Kiili 2005). This is
referred to as a game’s delity. In the past, a lot of effort has been put into creating
simulations that bare high physical delity to reality (i.e., the degree to which the
physical appearance replicates the real task), whereas it was thought that only per-
fect physical recreation of the task leads to learning. Therefore, much effort was put
into creating simulators in medical education, such as the virtual reality simulators
in laparoscopic surgery. However, it has become clear that for a game (or simulator)
to lead to skills transfer, its functional delity is most important. This refers to the
degree to which the instrument replicates specic cues on which decisions in reality
are based (Maran and Glavin 2003; Alexander et al. 2005). As long as problem-
solving in a serious game follows the same rules as the real-life situation it is meant
to support, the game’s contexts and graphical appearance are secondary to the learn-
ing result and can be adjusted to optimize the player’s immersion and ow.
10.4 Games forHealth
The earliest and most obvious goal for use of serious games in healthcare is to
change individuals’ behavior in order to promote health. These “health games” can
be specically designed to promote healthy behavior, but may also be commercial
games that serve general goals. These games fall in a wide range, including action
or sports games, played on platforms that can detect motion (e.g., Nintendo Wii™
or Kinect™), but can also include actions, role-playing, or puzzle games with an
element of strategy on mobile phones such as Pokémon Go™ (Niantic I 2016).
Health games were originally developed mostly for the younger generations as it
was believed to be most in line with their digital style of learning. Nowadays, they
come in many forms for all generations and cater to specic interests.
Systematic literature reviews summarize a large number of potential applica-
tions for games in health education, promotion, and management (Table10.1).
They are applied to promote physical tness (Exergames), for cognitive training
(Brain games), to promote knowledge and self-management in chronic diseases
and conditions (including asthma, diabetes, and obesity), and to reduce
psychological conditions and stress related to treatment (e.g., low self-esteem,
anxiety, and pain). Recently, Charlier etal. performed a systematic review of seri-
ous games directed specically at improving adolescents’ health behavior and
self-management in the context of chronic illness. They included nine randomized
M. Graaand and M. Schijven
Table 10.1 Summary of systematic reviews on the effectiveness of games for health
Article Game purpose
No. of
No. of
analysis Conclusions
Charlier etal.
education and
management in
9 7 RCTs
Yes Signicant
positive effect of
serious games on
health education
and self-
management in
Kueider etal.
training in
older adults
8 22 RCTs,
No Videogames
appear to be an
effective means of
enhancing reaction
time, processing
speed, executive
function, and
global cognition in
older adults.
Primack etal.
health and/or
38 NR RCTs
No Potential
benets of serious
games. Low-
quality evidence.
Guy etal.
34 21 All No Action
videogames use
can elicit light to
moderate physical
activity among
youth and increase
Evidence remains
DeShazo etal.
9 8 RCT,
No Games hold great
potential as an
modality for
education. Games
described are
exclusively for
children. Evidence
remains limited.
10 How Serious Games Wi ll I mprove Healthcare
controlled trials in a meta-analysis in which seven serious games were applied for
the management of asthma: Asthma Command (Rubin etal. 1986; Homer etal.
2000); Watch, Discover, Think, and Act (Bartholomew etal. 2000; Shegog etal.
2001); Wee Willie Wheezie (Huss et al. 2003); The Asthma Files (McPherson
2006); juvenile diabetes (DiaBetNet) (Kumar et al. 2004); Packy and Marlon
(Brown etal. 1997): and leukemia (Re-mission) (Kato etal. 2008). Results show
a combined signicant effect size of 0.361 (Hedges’ gu, 95% condence interval
0.098–0.624) on improving knowledge of the game groups versus the control
groups that received mostly written knowledge. On improving self-management
behavior, the effect size was 0.361in favor of the game group (Hedges’ gu, 95%
CI 0.122–0.497) versus control groups that did not receive any education (Charlier
etal. 2016). This study is the rst to prove that serious games can improve the
treatment of chronic disease in adolescents at the highest level of evidence (Grade
A recommendation, level 1a).
10.5 Rehabilitation
Because of the strong motivation and immersion that videogames exert on their
players, clinicians see them as interesting adjuncts to conventional physical reha-
bilitation in patients suffering from injury or disability. The spectrum varies from
complex immersive virtual reality systems (van Kerckhoven etal. 2014) to com-
mercially available games played on off-the-shelf game consoles (Saposnik etal.
2016). Rapid developments in motion detection systems in these consoles will make
Table 10.1 (continued)
Article Game purpose
No. of
No. of
analysis Conclusions
Adams (2010) Healthcare in
51 12 All No May be used for
health education
and training.
Evidence remains
education and
34 NR All No Games may
inuence young
knowledge, skills,
attitudes and
behavior in
relation to health
and physical
exercise. Evidence
remains limited.
NR=not reported, RCT=randomized controlled trial
M. Graaand and M. Schijven
these games easily accessible for large groups of patients in need for rehabilitation
on a global scale.
Saposnik etal. published a systematic review of the medical literature on the effec-
tiveness of virtual reality (VR) rehabilitation systems (including both immersive VR
systems and commercial videogames) for recovery of upper extremity motor function
after stroke (Saposnik etal. 2011). The authors describe 12 clinical trials and observa-
tional studies in which technology was applied to detect movement through cameras
and motion detection software or wearable devices with motion sensors. Limb func-
tion is then improved by through VR exercises (n=9) or (commercial) videogames
(n=3). Data from ve RCTs were pooled in a meta- analysis that showed a signicant
effect in favor of VR rehabilitation (OR 4.86, 95% CI 1.31–18.3, p < 0.02). The
authors view the lack of trials combining VR with conventional therapy as a major
shortcoming in current clinical practice (Saposnik etal. 2011).
Apart from rehabilitation in chronic conditions (e.g., cerebral palsy, multiple
sclerosis, stroke, and Parkinson’s disease), evidence is accumulating that also short-
and medium-term rehabilitation after trauma or orthopedic surgery is achievable
using serious games (Fig.10.2). Rehabilitation after burn injury using videogames
was shown to be equally effective as standard therapy, whereas videogame play
even resulted in less pain experienced (Parry etal. 2015). This may be the result of
a higher level of motivation and/or immersion, which perfectly exemplies the
major benet of videogames in this context. Videogames have great potential as
(adjuncts to) rehabilitation therapy in terms of cost reduction and effectiveness. The
rapid advances in VR and wearable technology are likely to boost their application
in the foreseeable future.
Fig. 10.2 In Revalidate™ (Motek (Amsterdam, The Netherlands)), in cooperation with Virtual
play (Utrecht, The Netherlands), a player trains his or her wrist function after trauma or surgery.
The controller attached to the player’s hand measures its posture, allowing the player to control the
turtle in the game to follow a specic course and score points. By introducing a fun and challeng-
ing aspect to rehabilitation, the producers hope to improve patients’ functional outcome after
10 How Serious Games Wi ll I mprove Healthcare
10.6 Crowdsourcing Science
Online multiplayer gaming communities often spend a vast number of hours playing
one single game—often in a social context (Entertainment Software Association 2016).
The scientic community has been trying to capitalize on this phenomenon, attempting
to use these massive amounts of human brainpower to solve complex or large-scale
problems for healthcare-related purposes such as unraveling complex three-dimensional
structures of specic proteins, DNA, and RNA. Foldit was developed by the University
of Washington’s Center for Game Science to allow non- scientists help unfold protein
structures (Cooper etal. 2010). In the serious game, players can improve their scores by
optimizing a given protein’s structure or reducing the amount of intrinsic energy
required, which is computed by a structure prediction model. One protein is presented at
a time, allowing multiple players to attempt to solve the puzzle, automatically checking
each other’s efforts. Foldit has over 300,000 registered users who already delivered over
5400 protein recipes (Khatib etal. 2011). The players’ efforts have resulted in real-world
improvements in computational enzyme design (Eiben etal. 2012). In a survey dis-
persed by the developers, players give the game’s competitive elements, social interac-
tion through chat and web community, as well as the possibility to unravel scientic
problems as main reasons to participate (Cooper etal. 2010).
Eyewire, developed by the Brain & Cognitive Sciences Department of the
Massachusetts Institute of Technology, is a multiplayer online puzzle game that involves
over 100,000 “citizen neuroscientists” in unraveling the structures of the mammalian
retina. A dataset containing 3D electron micrographs of a mouse retina is chopped into
little puzzle pieces and the players have to color subsets of individual neurons. The scor-
ing system rewards agreements between players coloring the same neurons. Using this
approach, “real” scientists were then able to reconstruct a connectivity model of the
mouse retina (Kim etal. 2014). Other scientic problems addressed by crowdsourcing
games are DNA multiple sequence alignment (Phylo) (Kawrykow et al. 2012), RNA
structure design (EteRNA) (Lee et al. 2014), gene–disease associations (Dizeez)
(Loguercio et al. 2013), and issues related to quantum physics (Quantum Moves)
(Sørensen etal. 2016).
10.7 The Gaming Doctor
In the last decade, the availability of serious games developed to train or educate
health professionals has increased rapidly. As Wang etal. (2016) showed in a system-
atic review, the number has increased from 4in 2007 (including two different genres)
to 42in 2014 (including eight different genres) (Wang etal. 2016). The scope has
widened from merely surgically oriented simulation games to almost all disciplines:
internal medicine, neurology, geriatrics, intensive care, emergency medicine, general
surgery, urology, obstetrics, pediatrics, pharmacy, nursing, pathology, and preclinical
medical education. Game types include simulations, quizzes, puzzles, adventure
games, and board games. The following three examples of educational serious games
M. Graaand and M. Schijven
give insight into the wide range of goals and design features. GeriatriX™ is a man-
agement simulation game aimed at teaching medical students how to deal with cases
in geriatric medicine in which cost consciousness, end-of-life decisions, and psycho-
social factors play a signicant part (Lagro etal. 2014). Dr. Game, Surgeon Trouble™,
is a simple arcade-type game (resembling Bejewled), in which equipment-related
malfunctions typical to laparoscopic surgery are concealed (Fig.10.3). The purpose
of the game is to train the surgeon’s situational awareness in a subtle, stealthy way
while they play an amusing arcade game (Graaand etal. 2014a). In the serious
game Underground™, the player has to build and manage an underground society of
trolls using Nintendo Wii™ controllers adjusted to resemble laparoscopic surgical
instruments (Fig.10.4). While playing a game that has seemingly little to do with
surgery itself, one acquires dexterity skills that can be translated to real-life laparo-
scopic surgery (Jalink etal. 2014a). All three serious games were the product of a
collaboration of medical educators and game designers.
Fig. 10.3 In Dr. Game: Surgeon Trouble™ (Weirdbeard, Co., Amsterdam, The Netherlands), the
trainee plays an amusing game on their smartphone (left) in which sudden changes may occur
resembling equipment-related problems during laparoscopic surgery. The player has to solve the
problem in a pop-up screen (right). The player learns surgical problem-solving skills while playing
an amusing game (©Weirdbeard Co.)
10 How Serious Games Wi ll I mprove Healthcare
Fig. 10.4 In Underground™ (Grendel Games, Leeuwarden, The Netherlands), the trainee con-
trols an underground society of trolls with two handles (depicted left and right) that resemble lapa-
roscopic surgical instruments attached to a Nintendo Wii™ game console. While playing a game
that has seemingly nothing to do with surgery, the player develops complex laparoscopic dexterity
skills (©Grendel Games)
Healthcare professionals will only accept games as tool for training or treatment if
their effectiveness has been scientically scrutinized. In their systematic review, Wang
etal. found that 33/42 serious games were subjected to (at least) one study evaluating
their efcacy as teaching intervention (Wang etal. 2016). They found a high heterogene-
ity in study design, with mainly positive results (only 11% of the studies found a nega-
tive result). Moreover, overall study quality was low (10.5 out of 18 points on the
MERSQI score (Reed etal. 2008)). This more or less coincides with earlier systematic
reviews, showing similar study quality and a limited amount of randomized controlled
trials (Graaand etal. 2012; Akl etal. 2013). To answer the question of whether serious
games are effective in general, one can merely conclude that there is sufcient evidence
that some serious games have a signicant effect on learning outcomes for healthcare
professionals (level 2, Grade B). However, these studies did not research skills transfer
to real-life (clinical) performance. Moreover, evidence of long-term learning retention is
limited (Wang etal. 2016; Graaand etal. 2012; Akl etal. 2013).
10.8 Games inOfcial Medical Programs: Seriously?
10.8.1 Validity
It needs to be emphasized that the overall effect of serious games in clinical education
or health promotion for individuals must not be confused with the effectiveness of
individual games (Schijven and Jakimowicz 2005). Because of the heterogeneity in
M. Graaand and M. Schijven
design aspects, target groups, and purposes, every newly developed game will require
a separate evaluation process—the gravity of which should be in accordance with the
game’s application. For instance, when applied to treating a sick patient or assessing
a surgeon before he or she will perform a real-life operation, a game’s assessment
system should be more rigorously tested than when used as an adjunct to promote fruit
and vegetable consumption in 5-year-old, otherwise healthy individuals. Consensus
on the level of evidence required for specic games is an ongoing topic of discussion
(Graaand etal. 2014b). However, there is a general need for systematic assessment
strategies to prevent false and incomplete claims of effectiveness.
A useful concept in this systematic approach is validity. Validity research is a
stepwise approach to evaluate various aspects of an instrument’s resemblance to a
real-life skill or performance parameter. The highest form of validity is predictive
validity—an instrument’s ability to improve skills in reality (Schijven and
Jakimowicz 2005; Gallagher et al. 2003; Youngblood and Dev 2005). Table10.2
shows the steps in the classical validity research processes applied most widely,
although the concept itself is the subject of ongoing debate (Cook etal. 2014).
For example, one cohort study compared the speed and movement efciency of
experienced surgeons playing Underground™ to novices (n=30) and found their
result to be signicantly faster (111%), thus proving its effectiveness in measuring
Table 10.2 Validity of research process
Validity type Description Criteria for achievement
The degree to which a game content
adequately covers the dimensions of
the medical construct it aims to
educate (or is associated with).
Uniform and positive evaluation of
game content and associated testing
parameters by expert medical specialist
Face validity Degree of resemblance between
medical constructs featured in
gameplay and in reality, as assessed
by novices (trainees) and experts
Uniform and positive evaluation of the
game as a valuable learning
environment among novice and expert
medical specialists.
Inherent difference in outcomes of
experts and novices on gameplay
outcome parameters.
Outcome differences considered to be
of signicance between players being
of different medical specialist levels of
Concordance of study results using a
concept instrument (e.g., game) and
study results on an established
instrument or method, believed to
measure the same medical theoretical
Outcome parameters show correlation
considered to be signicant between
game and an alternative, established
training method.
The degree of concordance of a
concept instrument (e.g., game)
outcome and task performance in
reality based on a validated scoring
Metrics show correlation considered to
be signicant between outcome
parameters of a game and performance
results on the medical construct
featured in the game in real life after
performers are trained using the game.
Adapted from Graaand etal. (2012)
10 How Serious Games Wi ll I mprove Healthcare
competence on this specic skill (Jalink etal. 2014a). A second cohort study found
that 97% of 34 pediatrics residents found the Bronx Jeopardy™ quiz game an easy-
to- use and effective learning tool through a questionnaire (Jirasevijinda and Brown
2010), proving the likelihood that residents are likely to accept it as a training
modality. However, the study setup and research purpose leads to the conclusion
that Underground™ can be regarded as a more reliable or valid training instrument
than Bronx Jeopardy™. In the rst case, the game shows to have clear construct
validity, whereas the second shows to have reasonable face validity.
10.9 Games inSkills Training Outside theOperating Room
Achieving an expert level in complex medical tasks requires prolonged deliberate
practice. This is more than mere repetition, which in itself leads to arrested develop-
ment over time. In deliberate practice, trainees require a well-dened goal, motiva-
tion to improve, feedback, and ample opportunity to repeat and rene their
performance (Ericsson 2006). Surgical postgraduate curricula aim to create profes-
sionals who are competent, and preferably procient, in essential surgical proce-
dures within approximately 1200h of operating time. Even though including the
time performing non-essential procedures approximately doubles this number, it
can be considered rather limited (Bell 2009; Chung 2005). Simulation and serious
gaming could play a signicant role in training and assessing performance in indi-
vidual procedures or activities, limiting the number of “ying hours” required inside
the surgical theatre (Bell 2009; Smith etal. 2009). Ideally, the objective measure-
ment of skills and progress within simulators and serious games could lead to a
system of accreditation and awarded responsibility. From this perspective, serious
games and simulators should not be regarded as two different entities, but rather as
two extremities from the same continuum of VR-enhanced training.
Virtual reality simulations have been developed and evaluated extensively for use in
medical training (Dawe etal. 2014; Cook etal. 2011). Well-known examples include
the minimally invasive surgical (MIS) simulators, developed for improving visuospa-
tial skills and dexterity. Simulators are able to produce standardized, reproducible vir-
tual surgical procedures. Their range encompasses basic task exercises (e.g., knot-tying
or artery clipping) to complete MIS procedures with distinct patient scenarios
(Schreuder etal. 2011). Surgical residents training on VR simulators work more ef-
ciently and make fewer errors than residents not trained using VR simulators (Gurusamy
etal. 2008; Ahlberg etal. 2007; Larsen etal. 2009). Simulators are able to give high-
delity procedural training, measure skills progression, and deliver direct feedback to
the trainee (Lamata de la Orden 2004). Thus, they are effective stand-alone training
instruments and incorporated in residency training curricula in many developed coun-
tries (Dutch Society for Endoscopic Surgery 2009; Hamming etal. 2009).
M. Graaand and M. Schijven
However, apart from basic dexterity training for various surgical procedures and
crew resource management in emergency situations, the integration of virtual real-
ity (VR)-enhanced simulation in medical and surgical training curricula has been
rather limited (Zevin etal. 2014). Lack of nancial investments and manpower form
practical hurdles in many hospitals. Next, the lack of structured, prociency-based
training curricula hinders the integration of simulation in the competency-based
training curricula (Zevin etal. 2014; Schijven and Bemelman 2011). Finally, most
commercially available VR simulators are frequently not seen as very motivating by
their users (van Dongen etal. 2008; Chang etal. 2007). One can imagine that repeat-
ing peg transfer in a box trainer will not trigger a busy adult healthcare profession-
al’s interest for long.
This is where gamication, serious games, and VR headset solutions—the sec-
ond wave of VR-enhanced learning—can play a major role. First, gamifying exist-
ing VR simulators, such as adding competitions and leaderboards, signicantly
increases its use by trainees (Verdaasdonk etal. 2009). Second, the design features
and game mechanisms discussed above will assist the development of immersive,
challenging educational instruments, tailored to a trainee’s specic level and
requirements (Dankbaar etal. 2014). Third, a new generation of VR head-mounted
displays and systems capable of overlaying the real world with digital features are
coming into play, varying from expensive headsets (e.g., Oculus Rift™, Samsung
Gear VR™) and simple cardboard headset boxes holding a smartphone (Google
Cardboard™) (Allaway 2015). These have great potential for creating complex and
blended simulations in medical postgraduate education.
10.10 Financial andEthical Aspects
Various nancial reimbursement strategies have been applied in medical serious
games in recent years. The most common model is where one or more health institu-
tions present as the sponsor of a game, making the investment necessary for its
production. The sponsor then distributes the game among patients or trainees (e.g.
Dr. Game, Surgeon Trouble™). The main disadvantage of this strategy is that the
sponsor may ultimately lose its interest or budget in the long run, threatening the
game’s development or maintenance.
A second model is when the game designer himself makes the investment for
production and distributes the game to clients (e.g. Underground™). This model
will naturally lead to better, high-quality products on the long term, but requires a
signicant investment from -often-small design companies. The designer runs the
risk of the game failing to produce the desired effectiveness or popularity.
Furthermore, designers often do not have the time or the budget to conduct scientic
10 How Serious Games Wi ll I mprove Healthcare
A third model is when a non-prot organization (university, hospital or govern-
mental organization) produces the game for free use to the public (e.g. Foldit™,
Re-Mission™). This model is mostly applied when the use of the game has a com-
mon public interest and/or charitable objective.
In order for the medical serious game market to become more mature and
independent on the long term, more rigid reimbursement models should be
implemented. Opportunities lie in involving the main stakeholders in the devel-
opment process, such as health insurance companies, patient organizations and
(inter-)national federations charged with training and education of medical
From an ethical perspective, it is important that serious games do not lead to
injuries or exacerbate diseases to their clients. Jalink etal. (2014b) published a sys-
tematic review on injuries caused by using the Nintendo game system. Apart from
bizarre injuries such as haemothorax by falling from a couch during gameplay, most
injuries described are relatively mild and non-specic. The authors conclude that
videogames do not appear to be a serious health threat. However, when specic seri-
ous games are designed to treat specic patients, rigorous testing and/or FDA
approval may be necessary before introduction to the market.
10.11 Discussion
Many tech hypes experience a period of disillusionment after an initial period of
rapid growth, whereas the eld of serious games in healthcare may be well have
bypassed this stage. The eld has diversied substantially and evidence on the
effectiveness of serious games is mounting among a variety of applications and
target groups. The technological advances continue to stride forward. For example,
the use of optical head-mounted displays can signicantly enhance the level of
immersion and delity of serious games in the near future. Wearable sensors com-
bined with motion detection software are already altering the eld of rehabilitation.
Applications that may render a virtual reality “layer” over the real world (augmented
reality) are available in smart visors (Hololens™, Google Glass™, Vuzix™, etc.)
but also on smartphones (Layar™). Combined with videogames, augmented reality
will lead to holistic, immersive, diversied experiences that can be used to educate
patients and professionals (Schreinemacher etal. 2014).
Although the future perspective for serious games is hopeful, there is still a mul-
titude of challenges to be overcome before they will become common clinical appli-
cations. First, healthcare professionals are—for good reasons—hard to convince of
the (cost-)effectiveness of new technologies. In contrast, the gaming industry is
pushing for rapid adaptation from a business point of view. Although game design-
ers and early medical adapters are starting to understand the importance of testing
and validating new serious games, the evidence still remains rather thin. The sys-
tematic reviews discussed in this chapter all conclude that the quality of present
clinical studies is moderate at best. There is a lack of randomized clinical trials and
M. Graaand and M. Schijven
there are few negative studies, indicating some form of publication bias. Second, no
evidence has been produced on the cost-effectiveness of game-enhanced therapies
and training. In the age of cost reductions in healthcare across many developed
countries, this potential benet of videogames requires more emphasis. Third, our
understanding on what motivates individuals to interact with a game remains very
limited. It is important to know what aspects trigger specic user groups in order to
predict the long-term effectiveness of games. In this context, so-called super-users,
players that spend an unusual amount of time and effort playing digital applications,
are thought to blur outcome statistics (van Mierlo etal. 2012).
Next to these scientic hurdles, practical issues need to be overcome as well. For
example, most “mainstream” clinicians and patients remain simply unaware of the
existence of relevant games let alone of the evidence supporting their use. Relevant
information on games and mHealth applications is often hard to nd in disorganized
app stores and claims of effectiveness are hard to judge. This will cause caution and
possibly even distrust among clinicians. Moreover, most clinicians are currently
unequipped to judge the validity of serious games.
The establishment of scientic conferences and journals directed at serious
games for healthcare purposes, such as Games for Health Journal (Baranowski
n.d.), BMJ innovations (Jha n.d.), and JMIR Serious Games (Eysenbach n.d.), have
greatly enhanced their visibility and awareness on importance to both the public and
healthcare professionals. Efforts have been made to construct validation frame-
works, to guide users in seeking the information necessary to judge a game’s pur-
pose, and effectiveness (Graaand etal. 2014b). To gain clinical exposure and
reduce our dependency on disorganized app stores, we recommend some form of a
publicly available library for medical serious games and comparable digital applica-
tions. Full transparency of serious games’ benets and limitations to both the public
and healthcare professionals will ultimately facilitate their adaptation in treatment
protocols and training curricula.
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10 How Serious Games Wi ll I mprove Healthcare
... O consenso sobre o nível de evidência necessário para jogos específicos é um tópico de discussão em andamento (Graafland & Schijven, 2018). No entanto, existe uma necessidade geral de estratégias de avaliação sistemáticas para evitar afirmações falsas e incompletas de eficácia. ...
... Sharifzadeh e colaboradores (2020) sugerem que os jogos devem ser desenvolvidos por equipas multidisciplinares para melhorar o design dos jogos, mantendo os utilizadores finais envolvidos para uma interação mais longa e resultados de (2017) reforçam este aspeto ao referir que os designers de jogos necessitam de trabalhar em estreita colaboração com os profissionais de saúde e pesquisadores, para incorporar os elementos teóricos e implementar os recursos do jogo com base em teorias, de modo a maximizar a eficácia do jogo e reduzir as suas possíveis desvantagens. Um outro aspeto salientado como desvantagem destes recursos consiste em manter o jogador envolvido no prepósito do jogo, potenciando a sua utilização e evitando o abandono (Graafland & Schijven, 2018). Pelo que, projetar jogos digitais para fins relacionados à saúde vai além da diversão e do entretenimento, onde, no desenvolvimento dos jogos devem ser considerados o conteúdo e o assunto, os utilizadores e o ambiente onde o jogo será jogado (Ghazisaeedi et al., 2017). ...
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Na abordagem a este tema, importa destacar os recursos tecnológicos eHealth e mHealth, apps e jogos. Salienta-se a importância da promoção da capacitação do outro para o seu autocuidado, através destes diversos recursos, que potenciem a motivação, facilitem a participação ativa do sujeito, fornecendo materiais educacionais. Ao recorrer ou prescrever estas intervenções, os enfermeiros precisam de adequar a sua adequabilidade destas intervenções ao contexto do indivíduo. Estes recursos têm e terão implicações na transformação dos cuidados de enfermagem, que devem ser estudados e equacionados num cuidado que poderá ser denominado de “Cuidado híbrido”. Estas ferramentas são projetadas para melhorar a vigilância da saúde, gestão do sistema de saúde, educação em saúde, tomada de decisão clínica e para apoiar mudanças comportamentais relacionadas às prioridades de saúde pública e gestão de doenças (WHO, 2016). Além disso, são promotores da transformação digital potenciando a qualidade na prestação de cuidados com foco nas necessidades das pessoas. Em suma, a adoção destes recursos tecnológicos possibilita que as organizações de saúde possam tomar decisões mais eficientes, perante um desafio ou oportunidade. Por outro lado, a implementação destas soluções digitais permite que os profissionais apostem na melhoria contínua, acrescentando valor aos cuidados de enfermagem. E por fim, permitem que os utentes se tornem mais ativos na autogestão da sua doença, promovendo o autocuidado em diferentes contextos de doenças crónicas.
... The growing interest in the use of games and simulations is evidenced in the medical domain (3). Various studies have established the potential of digital games to support health education (3)(4)(5). ...
... The growing interest in the use of games and simulations is evidenced in the medical domain (3). Various studies have established the potential of digital games to support health education (3)(4)(5). Simulated games can improve the acquisition and retention of clinical skills and the safety of patients (6). Nowadays, the internet and a wide range of mobile devices (i.e., mobile phones and tablets) are available to consumers. ...
Background: Nowadays, digital games are not just entertainment, but beside routine treatments, they are used in patient care, especially in patients with diabetes. Application of digital games in patient's education can improve self-management of diabetes. The aim of the present study was to evaluate the effect of a mobile game (Amoo) implementation on enhancing dietary information in patients with type 2 diabetes. Methods: A mobile game (called Amoo), which was developed by researchers of this study, was applied to assess the self-education of patients with diabetes. Sixty patients with type 2 diabetes participated in the study. The participants took part in a pre-intervention test to determine their dietary information. The participants were randomly divided into one of two groups, including the intervention group: played the game for 15 minutes daily for 6 weeks, and the control group: did not involve in the game. A post-intervention test was run to show a possible improvement in dietary information. Data were analyzed using paired t test and suitable non-parametric testes including Mann-Whitney and Wilcoxon signed rank tests as well as Spearman and Pearson correlation coefficients via IBM SPSS statistics version 21 (SPSS, v 21.0, IBM, Armonk, NY, USA). A P-value less than 0.05 was considered as a significant level. Results: The results indicated a statistically significant difference between the pre and post test scores in the intervention group (p<0.001). However, there was no significant difference in fasting blood sugar (p=0.125). Conclusion: The mobile game (Amoo) could enhance the knowledge of patients with type 2 diabetes about food calories and glycemic index. This means that mobile games may serve as an educational aid to these patients.
... O consenso sobre o nível de evidência necessário para jogos específicos é um tópico de discussão em andamento (Graafland & Schijven, 2018 (Ghazisaeedi et al., 2017). ...
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1-Introdução Não é novidade, que com os avanços da Medicina, muitas das situações de doença grave passaram a ser controladas e deixaram de ser uma ameaça de morte. Os progressos da ciência e da tecnologia, assim como das condições de vida e de saúde pública, conduzem um somar de anos à vida das pessoas. No entanto, viver mais tempo pode ter como consequência viver com doença crónica progressiva e avançada, em situação de fragilidade, por multimorbilidade, dependência para as atividades de autocuidado e declínio cognitivo até ao momento da morte. A investigação tem mostrado que as pessoas em fim de vida sofrem, porque, vivem perdas múltiplas em dimensões relevantes do ser humano. Perdas estas, no domínio físico, psicológico, social e espiritual. Os cuidados paliativos surgem no sentido da resposta abrangente e integrada às necessidades complexas das pessoas com doença crónica avançada e irreversível e com prognóstico limitado de vida, bem como, no acompanhamento de familiares e cuidadores durante as suas perdas e após o luto. Isto porque a necessidade de alívio do sofrimento e angústia severa, relacionados com condições de saúde que ameaçam ou limitam a vida são um imperativo global de saúde e de equidade (Knaul, Farmer, Krakauer, De Lima, Bhadelia., Kwete, 2017). Os cuidados paliativos são cuidados de saúde com o desígnio de ajudar a viver e a reduzir o sofrimento em circunstâncias extremas de fim de vida, diligenciam o acompanhamento centrado na pessoa e suas famílias, otimizando a qualidade de vida, o desenvolvimento do bem-estar humano e maximizando a dignidade dos cuidados. Devem ser prestados por equipas multidisciplinares e em diferentes contextos de saúde, porque lidar com o sofrimento envolve cuidar de questões que vão para além dos sintomas físicos. Os cuidados paliativos são consensualmente considerados um direito humano básico (Radbruch, De Lima, Lohmann, Gwyther & Payne, 2013). Devem fazer parte da oferta de serviços de qualquer sistema de saúde no sentido de garantir um apoio para que a pessoa possa viver o mais ativamente possível até à morte. O cliente alvo de cuidados paliativos pode ser identificado por um conjunto de sintomas ou fatores, incluindo a condição de doença crónica avançada, conjetura limitada de vida e necessidade de prevenção e alívio de qualquer tipo de sofrimento: físico, psicológico, social e espiritual, vivenciado por adultos ou crianças (WHPCA, 2014, 2020).
... O consenso sobre o nível de evidência necessário para jogos específicos é um tópico de discussão em andamento (Graafland & Schijven, 2018 (Ghazisaeedi et al., 2017). ...
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Face às constantes mudanças no panorama de saúde dos portugueses e nas necessidades em cuidados urge uma exaustiva avaliação dos resultados da sua implementação. É o momento de avaliar o seu impacte e agilizar os procedimentos necessários de melhoria das práticas assistenciais nesta área (Vilela, 2018). Têm surgido novas propostas de melhoria da tomada de decisão e organização do processo de cuidados, como a de Lopes que sugere a inclusão do “percurso de cuidados integrados à pessoa dependente” (2021, p. 220). O objetivo é melhorar a qualidade do atendimento em todo o continuum de cuidados, melhorando os resultados na pessoa, promovendo a sua segurança, aumentando a satisfação e otimizando o uso de recursos. Os cuidados em casa, parecem ser o futuro dos cuidados de longa duração, pois são menos onerosos para os Estados (Filipe, 2015). Acresce ainda que é nas suas próprias casas, que as pessoas, caso tenham os cuidados necessários e as condições, preferem ficar. Por isso, apostar em cuidados domiciliários profissionais, em substituição de aumentar as camas de internamento na rede, será o caminho e a resposta mais efetiva.
... Collaborative and competitive games were observed to increase motivation among individuals to play educational games, which further improves their understanding on the topics being taught, and hence have also been adopted in the healthcare domain [1,11,14]. StarsRace has been developed as a collaborative mobile game with an aim to control obesity by requiring players to virtually collect stars placed at specific geographical locations, by moving around the map physically [1]. LIVE has been developed as a virtual environment platform to facilitate learning of self-management skills and provides social support to diabetic patients [14]. ...
... Considering the playfulness and motivation inducing factor of games, they have been adapted in the healthcare domain to treat patients, to educate individuals about healthcare practices and motivate them to follow these practices, and also to train healthcare students [10,16,17]. ...
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Covid-19 has been affecting population across the world for more than an year, with diverse strains of this virus being identified in many countries. Vaccines to help in curbing the virus are being developed and administered. Preventing the spread of the disease requires collaborative efforts from everyone. People with varied professional backgrounds have varied responsibilities in controlling the pandemic. It is important that everyone is aware of their respective responsibilities and also empathize with efforts and duties of other individuals. It is here, we wish to leverage the potential of games in healthcare domain, towards educating about Covid-19. With an aim to educate the population about vaccination against Covid-19, responsibilities of citizens with varied professional backgrounds, and emphasize on the need for collaboration to fight against the pandemic, by following safety measures, we present SurviveCovid-19++, a collaborative multiplayer desktop based game. The game essentially revolves around four roles - doctor, sanitation worker, citizen and law enforcer, delivering their duties, following safety measures and collaboratively clearing multiple stages in the game. We have performed a preliminary evaluation of the game through a qualitative and quantitative user survey. The results of the user survey were encouraging, with volunteers expressing their increased empathy towards efforts of individuals with varied professional backgrounds, and better understanding of the importance of safety measures against Covid-19.
... They are used in a diversity of applications and in particular in medical education. In this latter field, in an attempt to foster engagement and fun, a category of serious games called serious simulation games adds gamification elements to computerized simulations of a clinical procedure (Graafland & Schijven, 2018). These serious games include leisure game design elements such as points, awards, badges, and game mechanics that define the rules for scoring, winning, and losing. ...
Background Cardiopulmonary bypass is a specialized technique requiring high technical skills and generic competencies. Methods The Virtual Perfusionist is a 3-dimensional serious game for training nurses in cardiopulmonary bypass management. The game design and the results of a preliminary usability analysis with a group of 28 perfusion nurse students are described. The games played, the errors, and their causes are analyzed. Students’ opinions are measured with an extended System Usability Scale. Results The game was well praised by attendees who could complete the learning objectives after a short period of familiarization with the technology. Conclusions The game was found useable and satisfying. Further studies will analyze its effectiveness in cardiovascular perfusion education.
... In a previous contribution, open innovation tactics were described that borrow elements of games (gamification), to marshal, contain, and facilitate the production of novel insight to scientific problems [46]. The interested reader is referred to [47,48] for a more recent summary of the use of 'Scientific Discovery Games' (SDG) in the context of biomedical research. ...
The past decade has seen significant growth in the use of ‘crowdsourcing’ and open innovation approaches to engage ‘citizen scientists’ to perform novel scientific research. Here, we quantify and summarize the current state of adoption of open innovation by major pharmaceutical companies. We also highlight recent crowdsourcing and open innovation research contributions to the field of drug discovery, and interesting future directions.
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Um modelo serve como um artefato que auxilia e guia o pensar para a tomada e justificativa de decisões relativas a um problema específico. Portanto, a representação gráfica destes modelos pode colaborar na compreensão do modelo. Este artigo analisa o design da informação de alguns modelos conceituais de jogos sérios para avaliar sua qualidade gráfica. Para tanto, foi realizada uma revisão sistemática de literatura em busca de modelos que auxiliassem no design e desenvolvimento de jogos sérios. Este artigo discute o design da informação destes modelos juntamente com a análise de seu conteúdo. Os resultados sugerem que a qualidade gráfica destes modelos é baixa o que dificulta explorar todos os recursos do modelo. _______________ A model works as an artifact that assists and guides thinking in making and justifying decisions related to a specific problem. Therefore, the graphic representation of these models can contribute to the understanding of the model. This article analyses the information design of some conceptual models of serious games to evaluate their graphic quality. To this end, a systematic literature review was carried out in search of models that would assist in the design and development of serious games. This paper presents the classification of graphic language by the Twyman matrix and discuss the graphic elements together with the content analysis of the model. The results suggest that the graphic quality of these models is low, which makes it difficult to explore all the features of the model.
Background and purpose Therapeutic decision-making is a critical part of the skill set required by practicing pharmacists. A potentially straightforward way to teach and evaluate decision-making skills is use of real-time simulations. This study aimed to evaluate pharmacy students' perceptions of using a real-time simulation game to treat their own virtual patient. Educational activity and setting Second professional year (Y2) and fourth professional year (Y4) pharmacy students were provided an opportunity to use a virtual patient simulation in their courses. Student perceptions of the game and use of the game for decision-making were evaluated by a questionnaire. The qualitative findings were analysed using an inductive thematic analysis. Findings The questionnaire was completed by 120 Y2 and 115 Y4 students. Four themes arose from the analysis that reflected the students' perceptions of autonomy in their learning and practice, the difficulty in committing to a decision, and having fun while learning. Summary This work provides an initial exploration of the perceptions of pharmacy students about playing a real-time, autonomous, simulation-based game for treating a patient. Future research should focus on more detailed evaluation of this game for learning therapeutic decision-making.
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We report on an online platform, Quantum Moves, which presents optimization problems in quantum physics as dynamic games. These games have so far been played 500,000 times. We observe that many of our players explore distinct solution strategies, which outperform numerical optimization algorithms. Combining the players' solutions with numerical methods we obtain a hybrid optimization algorithm that generates significantly improved results. We show that the hybrid solutions explore the most favorable regions of a complex, high-dimensional control landscape that we visualize here for the first time in quantum physics. This provides new insight into the failure of traditional gradient based optimization in quantum control and into the nature of the Quantum Speed Limit (QSL) appearing in optimization problems with bounded resources.
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To identify all reported cases of injury and other problems caused by using a Nintendo video gaming system. Review. Search of PubMed and Embase in June 2014 for reports on injuries and other problems caused by using a Nintendo gaming system. Most of the 38 articles identified were case reports or case series. Injuries and problems ranged from neurological and psychological to surgical. Traditional controllers with buttons were associated with tendinitis of the extensor of the thumb. The joystick on the Nintendo 64 controller was linked to palmar ulceration. The motion sensitive Wii remote was associated with musculoskeletal problems and various traumas. Most problems are mild and prevalence is low. The described injuries were related to the way the games are controlled, which varies according to the video game console. © Jalink et al 2014.
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As a surgeon you have a unique and best view on the operating field. No resident or intern will experience that same look and feel before being at the wheel themselves. Now, imagine the benefits of seeing through the surgeon’s eyes in this moment.
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The usefulness and effectiveness of specific serious games in the medical domain is often unclear. This is caused by a lack of supporting evidence on validity of individual games, as well as a lack of publicly available information. Moreover, insufficient understanding of design principles among the individuals and institutions that develop or apply a medical serious game compromises their use. This article provides the first consensus-based framework for the assessment of specific medical serious games. The framework provides 62 items in 5 main themes, aimed at assessing a serious game’s rationale, functionality, validity, and data safety. This will allow caregivers and educators to make balanced choices when applying a serious game for healthcare purposes. Furthermore, the framework provides game manufacturers with standards for the development of new, valid serious games.
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Background: Ototoxicity caused by medication can lead to debilitating symptoms such as dizziness, vertigo and postural instability. There is no current 'gold standard' treatment available. Case report: A 79-year-old male, with bilateral loss of vestibular function caused by gentamicin toxicity after surgery for prosthetic valve endocarditis, complained of dizziness, difficulty in walking and an increased risk of falling. Physical examination showed a positive head thrust test suggesting bilateral loss of vestibular function. Results: The patient underwent a specific motion-based virtual reality enhanced protocol for peripheral vestibular disease. He showed a great improvement, with a 50 per cent reduction in his Dizziness Handicap Inventory score. Conclusion: Computer-aided rehabilitation programmes might represent an important advance in gait and posture training.
Background: Non-immersive virtual reality is an emerging strategy to enhance motor performance for stroke rehabilitation. There has been rapid adoption of non-immersive virtual reality as a rehabilitation strategy despite the limited evidence about its safety and effectiveness. Our aim was to compare the safety and efficacy of virtual reality with recreational therapy on motor recovery in patients after an acute ischaemic stroke. Methods: In this randomised, controlled, single-blind, parallel-group trial we enrolled adults (aged 18-85 years) who had a first-ever ischaemic stroke and a motor deficit of the upper extremity score of 3 or more (measured with the Chedoke-McMaster scale) within 3 months of randomisation from 14 in-patient stroke rehabilitation units from four countries (Canada [11], Argentina [1], Peru [1], and Thailand [1]). Participants were randomly allocated (1:1) by a computer-generated assignment at enrolment to receive a programme of structured, task-oriented, upper extremity sessions (ten sessions, 60 min each) of either non-immersive virtual reality using the Nintendo Wii gaming system (VRWii) or simple recreational activities (playing cards, bingo, Jenga, or ball game) as add-on therapies to conventional rehabilitation over a 2 week period. All investigators assessing outcomes were masked to treatment assignment. The primary outcome was upper extremity motor performance measured by total time to complete the Wolf Motor Function Test (WMFT) at the end of the 2 week intervention period, analysed in the intention-to-treat population. This trial is registered with, number NTC01406912. Findings: The study was done between May 12, 2012, and Oct 1, 2015. We randomly assigned 141 patients: 71 received VRWii therapy and 70 received recreational activity. 121 (86%) patients (59 in the VRWii group and 62 in the recreational activity group) completed the final assessment and were included in the primary analysis. Each group improved WMFT performance time relative to baseline (decrease in median time from 43·7 s [IQR 26·1-68·0] to 29·7 s [21·4-45·2], 32·0% reduction for VRWii vs 38·0 s [IQR 28·0-64·1] to 27·1 s [21·2-45·5], 28·7% reduction for recreational activity). Mean time of conventional rehabilitation during the trial was similar between groups (VRWii, 373 min [SD 322] vs recreational activity, 397 min [345]; p=0·70) as was the total duration of study intervention (VRWii, 528 min [SD 155] vs recreational activity, 541 min [142]; p=0·60). Multivariable analysis adjusted for baseline WMFT score, age, sex, baseline Chedoke-McMaster, and stroke severity revealed no significant difference between groups in the primary outcome (adjusted mean estimate of difference in WMFT: 4·1 s, 95% CI -14·4 to 22·6). There were three serious adverse events during the trial, all deemed to be unrelated to the interventions (seizure after discharge and intracerebral haemorrhage in the recreational activity group and heart attack in the VRWii group). Overall incidences of adverse events and serious adverse events were similar between treatment groups. Interpretation: In patients who had a stroke within the 3 months before enrolment and had mild-to-moderate upper extremity motor impairment, non-immersive virtual reality as an add-on therapy to conventional rehabilitation was not superior to a recreational activity intervention in improving motor function, as measured by WMFT. Our study suggests that the type of task used in motor rehabilitation post-stroke might be less relevant, as long as it is intensive enough and task-specific. Simple, low-cost, and widely available recreational activities might be as effective as innovative non-immersive virtual reality technologies. Funding: Heart and Stroke Foundation of Canada and Ontario Ministry of Health.
Statement: Serious games are computer-based games designed for training purposes. They are poised to expand their role in medical education. This systematic review, conducted in accordance with PRISMA guidelines, aimed to synthesize current serious gaming trends in health care training, especially those pertaining to developmental methodologies and game evaluation. PubMed, EMBASE, and Cochrane databases were queried for relevant documents published through December 2014. Of the 3737 publications identified, 48 of them, covering 42 serious games, were included. From 2007 to 2014, they demonstrate a growth from 2 games and 2 genres to 42 games and 8 genres. Overall, study design was heterogeneous and methodological quality by MERQSI score averaged 10.5/18, which is modest. Seventy-nine percent of serious games were evaluated for training outcomes. As the number of serious games for health care training continues to grow, having schemas that organize how educators approach their development and evaluation is essential for their success.
To conduct a systematic review and meta-analysis of randomized controlled trials assessing the effectiveness of serious games in improving knowledge and/or self-management behaviors in young people with chronic conditions. The authors searched the databases PubMed, Cochrane Library, Web of Sciences, and PsychINFO for articles published between January 1990 and January 2014. Reference lists were hand-searched to retrieve additional studies. Randomized controlled trials that compared a digital game with either standard education or no specific education in a population of children and/or adolescents with chronic conditions were included. The authors identified 9 studies in which the effectiveness of serious games in young people with chronic conditions was evaluated using a randomized controlled trials design. Six studies found a significant improvement of knowledge in the game group from pretest to posttest; 4 studies showed significantly better knowledge in the game group than in the control group after the intervention. Two studies reported significantly better self-management in the game group than in the control group after the intervention. Seven studies were included in the meta-analysis. For knowledge, pooled estimate of Hedges' gu was 0.361 (95% confidence intervals, 0.098-0.624), demonstrating that serious games improve knowledge in patients. For self-management, pooled estimate of Hedges' gu was 0.310 (95% confidence intervals, 0.122-0.497), showing that gaming improves self-management behaviors. The authors' meta-analysis shows that educational video games can be effective in improving knowledge and self-management in young people with chronic conditions. © The Author 2015. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For Permissions, please email: For numbered affiliations see end of article.